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0 Other FEE <br />0 Food Hand - r <br />VOICE # D <br />F 48-02-034 MASTERFILE -E ORD INFORMATION PINK <br />1/23/13 <br />ACCOUNTING OFFICE REVIEWED BY <br />/6 2,S FEE LI Surcha •e - <br />to <br />--Date <br />PROGRAM ELEMENT <br />INSPECTOR # <br />LI Check # <br />LI Cash <br />PERMIT VALID <br />AMOUNT PAID <br />Date 2-- <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTERFILE RECORD INFORMATION FORM <br />0 New EH Program at Existing Facil)_it <br />Facility ID ft-2-1,77 tr2 <br />0New EH Pro ram and New Facili <br />Program Record ID f < <br />Facility Address 1261 VV YOSEMITE AVE, MANTECA, CA 95337 <br />(Please check the appropriate description and specify size, number of units <br />FOOD PROGRAM (1600) <br />II Restaurant: Seating Capacity 99 Square Footage 3,000 <br />Commissary El Dry storage only 0 with Food Preparation <br />Retail Market----Square footage LI w/Meat Market only <br />Mobile Food Vehicle --Make Vehicle Type <br />Registration # License # <br /> Sticker # <br />Mobile Food Prep Unit-- Make Vehicle Type Color <br />Registration # License # <br /> <br />Sticker # <br />LI Temporary Food Facility --Dates of operation from to <br />Special Event---Dates of operation from to EICFO LAUB <br />DAIRY PROGRAM (2000) <br />LI Grade A Dairy <br />CUPA <br />0 Grade B Dairy 0 Milk Dispenser -Number of Containers in Multi-Head Unit <br /> <br />LI Hazardous Materials Business Plan (1900) Number of chemicals: <br />LI CalARP Program 0 Program 1 Facility 0 Program 2 Facility 0 Program 3 Facility <br />Hazardous Waste Generator (2200) >-Tons Generated Per Year <br />Tiered Permitting Facility > 0 CA (2232) 0 CE (2233, 2234, 2235, 2237) 0 PBR (2231) 0 PBR HHW (2236) <br />Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br />Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br />Other CUPA Program <br />HOUSING PROGRAM (2400) <br />Hotel/Motel Number of Units 0 Jail or Exempt Institution ----Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br />Environmental Assessment 0 UST-CAP Site 0 Local HW Cleanup Site 0 NPL/SEP Cleanup Site 0 UIC Site <br />Abandoned HW Site LI non-NPL/SEP Cleanup Site 0 RWQCB Cleanup Site 0 Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility 0 Pool 0 Spa 0 Out of Service Pool/Spa 0 Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />Poultry Farm Maximum number of birds 0 Kennel <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br />Body Art Practitioner Reg (4110) 0 Mechanical DSPS Notification (4115) 0 Body Art Facility-Single Use (4120) <br />Body Art Facility-Sterilization (4121) 0 Body Art Temp Event Co-ord (4130) El Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br />Pumper Vehicle Registration # <br /> <br />License # Capacity Vehicle # <br />Pumper Yard 0 Package Treatment Plant 0 Chemical Toilets ----Number of Units <br />SOLID WASTE PROGRAM (4400) <br />Landfill CI Transfer Station LI Ag/Cannery Waste Site <br />Waste Tire Facility 0 Compost Facility 0 Process/Recycle Facility <br />Refuse Vehicles (# of Units) LI Dumpsters > 20 Cu yd (# of Units) <br />MEDICAL WASTE PROGRAM (4500) <br />Primary Care 0 Acute Care 0 Skilled Nursing 0 Large Generator 0 Small Generator 0 Limited Hauler <br />Transfer Station LI Veterinary Clinic <br /> 0 Common Storage Facility 0 2 - 10 0 11 - 60 0 > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON JASHANJIT SINGH Day Ph 209-802-1313 Night Ph 209-802-1313 <br />and pertinent information ) <br />Food Handlers Course required: YES El No 0 <br />ElVending Machines Number of Units <br />0 Multiple Departments 0 Prepackaged Goods Only <br />Color <br />1:1 Ice Plant El Produce Stand <br />11 Sludge/Ash Site <br />0 CIA Landfill Site <br />0 Farm/Ranch Cleanup Site